Minutes

The University of Toledo Board of Trustees

Clinical Affairs Committee Meeting

November 16, 2015

Committee Chair Mr. Gary P. Thieman was present with Committee members Dr. S. Amjad Hussain, Mr. Joseph H. Zerbey, IV as well as Student Trustees Mr. Daniel D. Arendt and Ms. Anna L. Crisp. Other Trustees who attended included Mr. Steven M. Cavanaugh, Mr. Jeffrey C. Cole, Ms. Mary Ellen Pisanelli and Ms. Sharon Speyer. Faculty Representative Ms. Kandace Williams was also present. Others in attendance were Mr. Daniel Barbee, Ms. Brandi Barhite, Mr. John Barrett, Dr. Christopher Cooper, Ms. Meghan Cunningham, Dr. Sharon Gaber, Dr. Bryan Hinch, Dr. Kristen Keith, Mr. Chuck Lehnert, Ms. Vanessa McCray, Mr. William McCreary, Dr. William Messer, Jr., Mr. David Morlock, Mr. Peter Papadimos, Dr. Thomas Schwann, Mr. Allen Seifert, Ms. Joan Stasa, Mr. Nickolas Vitale, Ms. Jessica Weimer, and Dr. Frederick Williams. /

ATTENDANCE

The meeting was called to order at 10:30 a.m. by Trustee Thieman at the Driscoll Alumni Center in the Schmakel room. / CALL TO ORDER
Trustee Thieman requested a motion to waive the reading of the minutes from the October 12, 2015 Committee meeting and approve them as written. A motion for approval was received from Trustee Zerbey, seconded by Trustee Hussain, and approved by the Committee. / APPROVAL OF MINUTES
Dr. Thomas Schwann, Chief of Cardio Surgery/UTMC Chief of Staff, presented the Committee members with information about the bi-annual medical staff reappointment process. He reported that the current process includes reappointment of approximately one-half of the staff in April each year or 150 to 200 applications. This current process overburdens the Clinical Affairs Committee, the Clinical Verification Office, medical staff resources, and presents potential errors. Dr. Schwann proposed an alternative quarterly reappointment process as follows:
·  By department/specialty
·  Approximately 50-60 reappointments quarterly (February, May, August, November)
·  More manageable
·  Continuous versus episodic process
·  More predictable and accurate
·  Multiple reappointments to place provider on department specific schedule / MANAGEMENT OF REAPPOINTMENTS AND RE-CREDENTIALING
Dr. Schwan proposed discussions about the Medical Staff bylaws review. Trustee Pisanelli recused herself from the discussions and exited the meeting room. Dr. Schwan indicated that the current Medical Staff bylaws are more suitable for a community hospital with non-employed medical staff. The current bylaws are outdated and were last reviewed in 2012. The amended bylaws will include a harmony of purpose between the Board of Trustees, administration, the medical staff and the community. They will be more suitable for an academic institution with employed medical staff and compliant with and reflective of a rapidly evolving healthcare environment and institutional changes. Dr. Schwan reported that the final version will be available in January 2016. The first quarter of 2016 will involve the Medical Executive Committee’s approval with the Medical Staff approval by a simple majority. The second quarter will provide revisions if needed, approval by the Board of Trustees, and adoption. / MEDICAL STAFF BYLAWS REVIEW
Dr. Bryan Hinch, Assistant Professor of Medicine, was invited to present an update about inpatient electronic medical records (EMR) discussions and meetings. He provided information about sun setting McKessen, the current EMR system. “Core” clinical products were reported as documentation, order entry, and results review while ancillary systems were described as Pharmacy, Operating Room management, Emergency Department tracking board, etc. These are critical parts of the system that the hospital depends on. Dr. Hinch presented a timeline to meet critical Meaningful Use deadlines. He indicated that UTMC leadership has taken a deliberative approach assessing the benefits and risks of the options and have entered into discussions with an outside healthcare consultant firm called Gartner. Each option reviewed was presented to the Committee which indicated that the benefits, costs and risks differ substantially between each option. Athena was recommended for the inpatient electronic medical record partner with justification provided. Risk mitigation was also discussed with the Committee. Much discussion ensued about this decision. / INPATIENT ELECTRONIC MEDICAL RECORDS
Trustee Thieman requested a motion to enter Executive Session to discuss privileged information related to the evaluation of medical staff personnel appointments and quality reporting. The motion was received by Trustee Zerbey, seconded by Trustee Hussain, and a roll call of the Committee was taken by Ms. Stasa: Dr. Hussain, yes; Mr. Thieman, yes; and, Mr. Zerbey, yes. After discussions were finished, the Committee exited Executive Session. / EXECUTIVE SESSION
Dr. Hussain requested a motion to approve the Chief of Staff Report as presented in Executive Session. The Chief of Staff Report included: 7 new medical staff applications; 3 new Allied Health professional staff applications; 6 medical staff and Allied Health Professional reappointments; 1 request for additional privileges; 2 completed Focused Professional Practice Evaluations (FPPE) with acceptable outcomes and request for move into Ongoing Professional Practice Evaluation (OPPE); 40 completed OPPE with acceptable outcomes (11 of these had no clinical data available for this review period); and, 5 resignations. A motion for approval was received from Trustee Hussain, seconded by Trustee Zerbey and approved by the Committee. / CHIEF OF STAFF REPORT
With no further business before the Committee, Trustee Thieman adjourned the meeting at 11:50 a.m. / ADJOURNMENT


CHIEF OF STAFF REPORT

November 16, 2015

New Medical Staff Applications

Shaza Aouthmany, MD

Emergency Medicine

Emergency Medicine - Active

Burton Brodsky, MD

Obstetrics & Gynecology

Obstetrics & Gynecology - Active

Kettlie J. Daniels, MD

Psychiatry

General Psychiatry – Active

Jennifer-Kris B. Hao, MD

Internal Medicine /Endocrinology

Endocrinology - Active

Chiamaka Mbaso, MD

Internal Medicine

Internal Medicine

Ganesh P. Merugu, MD

Family Medicine

Family Medicine – Active

Megan Williams, MD

Emergency Medicine

Emergency Medicine - Active

New Allied Health Professional (AHP) Staff Applications

Emilee Dirr, MSN, CNP

Orthopaedic Surgery - AHP

Collaborating Physician – Nabil Ebraheim, MD

Ashley Schiefer, PharmD

Internal Medicine - AHP

Sponsoring Physician – Carl Sirio, MD

Colleen Taylor, PHD, CNP

Family Medicine - AHP

Collaborating Physician – Jyothi Pappula, MD

Medical Staff and Allied Health Professional Reappointments

Rosemary D'Agostino, MD

Pediatrics

Scott Frederick, MD

Internal Medicine

Anne Mullins, LISW, S

Psychiatry - AHP

Tausha Sharples, LPCC, S

Psychiatry - AHP

Victoria Shiple, MSN, CNP

Internal Medicine/Cardiology – AHP

Michael Tricoci, MD

Emergency Medicine

Request for Additional Privileges

Samay Jain, MD

Urology

Fluoroscopy

Completed FPPE with acceptable outcomes, move into OPPE

Kelli Cole, PharmD

Internal Medicine / Infectious Diseases

Julie Murphy, PharmD

Internal Medicine

Completed OPPE with acceptable outcomes

See attached lists

Medical Staff and Allied Health Professional Resignations

Luis Espinoza, RNFA - Resigned effective 9/30/15

Laura Limpert, LISW-S - Resigned effective 10/23/15

Heidi Olszewski, LISW-S - Resigned effective 10/5/15

Eugene Simon, MD - Resigned effective 9/24/2015

Richard Ziegler, DDS - Retired effective 12/31/2


OPPE - Psychiatry

09/01/2014 - 04/30/2015

Completed OPPE with acceptable outcomes for the following practitioners:
Jason Bombard, MD
Carol Budzenski, PhD
Tom Fine, LPCC
Suzanne Hall, LPCC
Kim Hunter, PhD
Michele Knox, PhD
Sandra McCluskey, LPCC
Ronald McGinnis, MD
Angela McGrady, PhD
Jill McLaughlin, LISW
A. John McSweeny, PhD
Alina Rais, MD
Theodore Rais, MD
Daniel Rappport, MD
Tabinda Rehman, MD
Alan Mendel, LISW, LPCC
Heidi Olszewski, LISW
Amy Riese, MD
Lori Rokicki, PhD
Tausha Sharples, LPCC
Tanvir Singh, MD
Jennifer Smirnoff, MD
Marijo Tamburrino, MD
Kristi Williams, MD
John Wryobeck, PhD
Jeff Ziegler, LPCC
No clinical data available for this review period for the following practitioners:
Richard Baron, LISW
Jason Brower, PhD
Nancy Carroll, MD
Liza Halloran, PhD
Alamdar Kazmi, MD
Tracy Kempton, PhD
John Lawrence, PhD
Sonja Pinsky, MD
Agha Shahid, MD
Mary K. Smith, MD
Tim Wynkoop, PhD

OPPE – Other Specialties

09/01/2014 – 04/30/2015

Completed OPPE with acceptable outcomes for the following practitioners:

Mouhammad Jumaa, MD – Neurology

Youngsook Yoon, MD – Pulmonary/Critical Care

James Young, MD – Emergency Medicine